Formulary
Esketamine: Indications, Dosing, Side Effects and Interactions
Esketamine is an isomer of ketamine that blocks N-methyl-D-aspartate (NMDA) receptors and interrupts the association pathways of the brain, resulting in...
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Esketamine: Indications, Dosing, Side Effects and Interactions
Esketamine is an isomer of ketamine that blocks N-methyl-D-aspartate (NMDA) receptors and interrupts the association pathways of the brain, resulting in...
Drug action
Esketamine is an isomer of ketamine that blocks N-methyl-D-aspartate (NMDA) receptors and interrupts the association pathways of the brain, resulting in dissociative anaesthesia and analgesia and in restoration of neural pathways regulating mood and emotional behaviour.
Indications and dose
**Induction and maintenance of anaesthesia (specialist use only)**
- **Adult** (By Slow Intravenous Injection): 0.5-1 mg/kg, then maintenance 0.25-0.5 mg/kg every 10-15 minutes, adjusted according to response.
- **Adult** (By Intramuscular Injection): 0.5-3 mg/kg/hour, adjusted according to response.
**Analgesia in emergency medicine (specialist use only)**
- **Adult** (By Intramuscular Injection): 0.25-0.5 mg/kg, adjusted according to response.
- **Adult** (By Slow Intravenous Injection): 0.125-0.25 mg/kg, adjusted according to response.
Cautions
General cautions: History of drug abuse; hypertension; raised intracranial pressure; thyroid dysfunction Specific cautions: When used for Analgesia in emergency medicine Chronic or acute alcohol consumption; decompensated cardiac failure; increased cerebrospinal fluid pressure; patients with multiple injuries or in poor condition-consult product literature; prolapsed umbilical cord; raised intra-ocular pressure; severe psychotic disorders; unstable angina pectoris; uterine rupture When used for Analgesic supplementation of regional and local anaesthesia Chronic or acute alcohol consumption; decompensated cardiac failure; increased cerebrospinal fluid pressure; patients with multiple injuries or in poor condition-consult product literature; prolapsed umbilical cord; raised intra-ocular pressure; severe psychotic disorders; unstable angina pectoris; uterine rupture When used for Induction and maintenance of anaesthesia Chronic or acute alcohol consumption; decompensated cardiac failure; increased cerebrospinal fluid pressure; patients with multiple injuries or in poor condition-consult product literature; prolapsed umbilical cord; raised intra-ocular pressure; severe psychotic disorders; unstable angina pectoris; uterine rupture When used for Major depressive disorder Bipolar disorder (active or previous history); cardiovascular conditions (clinically significant or unstable); mania (active or previous history); psychosis (active or previous history); respiratory conditions (clinically significant or unstable) Cautions, further information History of drug abuse When used for Major depressive disorder: Patients should be assessed for the risk of drug abuse prior to starting treatment, and monitored for signs of this during therapy. M Cardiovascular or respiratory conditions When used for Major depressive disorder: Esketamine should be administered where appropriately trained staff and resuscitation facilities are available.
Contraindications
General contra-indications: Acute porphyrias ; patients in whom hypertension or raised intracranial pressure forms a serious risk Specific contra-indications: When used for Analgesia in emergency medicine Eclampsia; ischaemic cardiac disorders (when used as sole anaesthetic agent); pre-eclampsia When used for Analgesic supplementation of regional and local anaesthesia Eclampsia; ischaemic cardiac disorders (when used as sole anaesthetic agent); pre-eclampsia When used for Induction and maintenance of anaesthesia Eclampsia; ischaemic cardiac disorders (when used as sole anaesthetic agent); pre-eclampsia When used for Major depressive disorder Aneurysmal vascular disease; cardiovascular events, including myocardial infarction (within 6 weeks); intracerebral haemorrhage
Side effects
General side-effects: Common or very common Anxiety; dizziness; nausea; vomiting Specific side-effects: Common or very common With intranasal use Drowsiness; dry mouth; dysarthria; feeling abnormal; feeling of body temperature change; hallucinations; headache; hyperacusia; hyperhidrosis; hypertension; mood altered; nasal complaints; oral disorders; perception altered; psychiatric disorders; sensation abnormal; tachycardia; taste altered; tinnitus; tremor; urinary disorders; vertigo; vision blurred With parenteral use Arrhythmias; hypersalivation; movement disorders; respiratory disorders; respiratory secretion increased; sleep disorders; vision disorders Uncommon With parenteral use Muscle tone increased; nystagmus; skin reactions Rare or very rare With parenteral use Hypotension Frequency not known With intranasal use Cystitis With parenteral use Disorientation; drug-induced liver injury; dysphoria; hallucination
Pregnancy
When used for Induction and maintenance of anaesthesia or Analgesic supplementation of regional and local anaesthesia or Analgesia in emergency medicine: Manufacturer advises use only if potential benefit outweighs risk-may depress neonatal respiration if used during delivery. When used for Major depressive disorder: Manufacturer advises avoid-no information available.
Breast feeding
When used for Induction and maintenance of anaesthesia or Analgesic supplementation of regional and local anaesthesia or Analgesia in emergency medicine: Manufacturer advises present in milk-not thought to be harmful at therapeutic doses. When used for Major depressive disorder: Manufacturer advises avoid-present in milk in animal studies.
Hepatic impairment
When used for Induction and maintenance of anaesthesia or Analgesic supplementation of regional and local anaesthesia or Analgesia in emergency medicine: Manufacturer advises caution (risk of prolonged action). When used for Major depressive disorder: Manufacturer advises caution in moderate impairment when using maximum dose (84 mg); avoid in severe impairment-no information available. Dose adjustments When used for Induction and maintenance of anaesthesia or Analgesic supplementation of regional and local anaesthesia or Analgesia in emergency medicine: Manufacturer advises consider dose reduction.
Medicinal forms
Solution,Spray
Clinical governance
**Author:** MedNext Clinical Team. **Clinical reviewer:** Dr Shameer Deen, MBBS, MS, MRCS. **Sources:** BNF, Indian Pharmacopoeia, CIMS India. **Correction:** Report errors at support@mednext.academy.
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